Acute Otitis Media

SUMAYA JAMAL
Objectives
1. To Review important middle ear anatomy and
physiology.
2. To get an idea about the differences in Eustachian
Tube between adults and pediatrics, and how that
can affect the pathogenesis of otitis media.
3. To define the otitis media and its different subtypes.
Anatomy

The middle ear includes:

1. Tympanic membrane
2. the tympanic cavity
3. Ossicles
Anatomy
Tympanic membrane
 Oval & thin ,semi-transparent, divided into 2 parts: the
pars flaccida & the pars tensa.
 The manubrium of the malleus is firmly attached to the medial
tympanic membrane; where a concavity is formed. The apex of this
concavity is called the umbo.
 The sensory nerve supply to the tympanic membrane
includes the following:
1. Auriculotemporal nerve (mandibular branch of
trigeminal nerve)
2. Auricular branch of vagus nerve.
3. Tympanic branch of glossopharyngeal nerve (Jacobson
nerve)
 Otoscopic image (panel A) and schematic diagram (panel B) of a left tympanic
membrane. A line drawn along the manubrium of the malleus divides the tympanic
membrane into anterior and posterior halves (dashed line). A line drawn through the
umbo (perpendicular to the first line) divides the tympanic membrane into superior
and inferior halves (solid line).

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Anatomy
Tympanic cavity
Divided In To 3 Parts:
1. Epitympanum (Attic)
2. Mesotympanum
3. Hypotympanum
 Multiple structures are contained within the confines of
the tympanic cavity
 The cavity is covered in mucoperiosteum.

 The middle ear inhabits the petrous portion of the

temporal bone and is filled with air secondary to
communication with the nasopharynx via the auditory
(eustachian) tube
Anatomy
Tympanic cavity
 The lateral wall contains the tympanic membrane ,lesser extend
by bony outer attic wall (SCUTUM)
 The posterior wall contains the mastoid antrum and
communicates with the mastoid air cells
 The medial wall contains promontory ,the oval window & the
round window this wall is also called the labyrinthine wall
 The anterior wall is also termed the carotid wall, because a thin
plate of bone separates the carotid canal and tympanic cavity and
also houses the auditory tube
 The roof of the tympanic cavity is the tegmental wall
 The floor of the middle ear is the jugular wall; it separates the
tympanic cavity from the internal jugular vein
Right medial wall of the middle ear
Right lateral wall of the middle ear
Anatomy
Eustachian tube
 Eustachian tube is the communication between the middle
ear and the nasopharynx.
 Lumen shaped like two cones with apex directed toward
middle
 Mucosa has mucous producing cells and ciliated cells
 Usually closed
 Opens during swallowing, yawning, and sneezing
 Lumen opens when attachment of tensor veli palatini muscle
pulls wall of tube laterally during swallow.

 Auditory tube close by elastic recoil of cartilage, tissue

turgidity and tension of salpingopharyngeus muscle.
Anatomy
Anatomy
The pharyngeal opening is:
 Below the level of the hard palate in the fetus.
 Is level with the palate at birth.
 Is 3 to 4 mm. above it at the fourth year.
 Is 10 mm. Above it as an adult
 Lumen of tube in child is more horizontal and wider
Functions :
 Protection from nasopharyngeal sound and secretions
 clearance of middle ear secretions
 ventilation (pressure regulation) of middle ear
Anatomy
Eustachian tube
 Two Parts : 2. Salphingo pharyngeus:
1. Bony part (12mm) 3. Levator veli palati
2. Cartilagenous part(24mm) Nerve supply for these muscles
 Muscles attached: =pharyngeal plexus

1. Tensor veli tympani:

nerve supply from :mandibular
nerve separate tube from
otic ganglion
mandibular nerve
chorda tympani
middle meningeal artery
Nerve Supply
 Sensory & parasympathetic : tympanic branch of
glossopharyngeal N
 Tensor veli palatini: V3
 Levator veli palatini pharyngeal plexus
 Salpingopharyngeus (cranial part of XI N via vagus)
Anatomy
Muscles
 Stapedius muscle, which connects the neck of the stapes to the
posterior tympanum.
 Innervation is provided by the nerve to the stapedius from the facial
nerve
 Contraction displaces the stapes posteriorly and functions to prevent
loud noises from injuring the inner ear.

 The tendon of the tensor tympani attaches to the manubrium of the

malleus
 Innervated by the mandibular branch of the trigeminal nerve
 contraction of the tensor tympani displaces the malleus medially
 Eustachian tube obstruction
 Anatomic obstruction is most commonly caused by inflammation of
the eustachian tube mucosa or extrinsic compression by tumor or large
adenoids.
 Functional obstruction usually occurs as a result of either the failure
of the normal muscular mechanism of eustachian tube opening, as
seen in cleft palate, or insufficient stiffness o the cartilaginous
portion of the eustachian tube, often seen in infants and young
children.
 The more acute angle of the eustachian tube seen in children,
compared with adults, may also result in the impaired function of the
eustachian tube opening.
 These abnormalities are often seen in patients with Down syndrome,
which may account for the high rate of OM .
 Normal function of the eustachian tube is also dependent on ciliary
function
Eustachian tube dysfunction


– Retracted TM
– Otalgia
– Congestion along the
– Hearing loss handleof malleus and pars
– Popping sensation tensa
– Tinnitus – Transudate behind TM
– Disturbances of
equilibrium
Eustachian tube dysfunction

– Upper respiratory tract infection

– Allergy
– Sinusitis
– Nasal polyps
– Nasal septum deviation
– Hypertrophic adenoids
– Nasopharyngeal tumour/ mass
– Cleft palate
– Submucous cleft palate
– Down’s syndrome
 Eustachian tube dysfunction

Treatment :
 Decongestant nasal sprays or drops
 Antihistamine.
 Steroid nasal spray
Acute Otitis Media (AOM)
TERMINOLOGY
MEE) —refers to fluid in the
middle ear cavity. MEE occurs in both otitis media
with effusion and AOM.
AOM) —refers to acute infection
of middle ear fluid.
— Otitis media with
effusion (OME) refers to middle ear fluid that is not
infected.
 OME is also called serous, secretory, or nonsuppurative
otitis media.
 OME frequently precedes the development of AOM or
follows its resolution.
Classification of AOM

Suppurative

Nonsuppurative

Recurrent
AOM
RISK FACTORS
A number of risk factors for AOM have been established, the

most of important of which is age.
1. Age – The age-specific attack rate for AOM peaks between 6
and 18 months of age
2. Family history
3. Day care – The transmission of bacterial and viral pathogens
is common in day care centers.
4. Lack of breastfeeding – Lack of or limited breastfeeding is
associated with an increased risk of AOM
5. Tobacco smoke and air pollution
6. Low income countries – Lack of access to medical care and
local environmental factors lead to severe suppurative
episodes of OM in children living in developing areas
Cont’ Risk factors

 Other risk factors – Other important risk factors in the

development of single and recurrent episodes of AOM
include [18]:
•Social and economic conditions (poverty and household
crowding increase the risk)
•Season (increased incidence during the fall and winter
months)
•Altered host defenses and underlying disease (eg, HIV,
cleft palate, Down syndrome, allergic rhinitis)
AOM
Pathogenesis
The pathogenesis of AOM in at-risk children generally involves the
following sequence of events
1. The patient has an antecedent event (usually a viral upper
respiratory tract infection) while colonized with an
otopathogen(s) . Some evidence suggest that co-colonization
with bacterial otopathogens only, in the absence of viral
respiratory tract infection, may be sufficient to trigger the
cascade of events .
2. The event results in inflammatory edema of the respiratory
mucosa of the nose, nasopharynx, and eustachian tube.
3. Inflammatory edema obstructs the narrowest portion of the
eustachian tube, the isthmus.
4. Obstruction of the isthmus causes poor ventilation and resultant
negative middle ear pressure. This leads to the accumulation
of secretions produced by the middle ear mucosa.
5. The secretions have no egress and accumulate in the middle ear
space.
6. Viruses and bacteria that colonize the upper respiratory tract
enter the middle ear via aspiration, reflux, or insufflation.
7. Microbial growth in the middle ear secretions often progresses to
suppuration with clinical signs of AOM (bulging tympanic
membrane [TM], middle ear fluid, erythematous TM).
8. The middle ear effusion may persist for weeks to months
following sterilization of the middle ear infection.
AOM
MICROBIOLOGY
 Bacteria — Three species of bacteria account for most
of the bacterial isolates from middle ear fluid:

1. S. pneumoniae app. 50 % of severe

cases
2. Nontypeable H. influenzae (NTHi),
app 45% of severe cases
3. Moraxella catarrhalis.
AOM
MICROBIOLOGY
 Bacterial and/or viral respiratory tract pathogens can be
isolated from most middle ear aspirates from children with
AOM.
 The finding of combined bacterial and viral infections in
two-thirds of cases has important clinical implications
.Mixed viral and bacterial infections may respond
differently to antibiotic therapy than purely bacterial
infections. The presence of viruses may increase middle
ear inflammation ,decrease neutrophil function , and
reduce antibiotic penetration into the middle ear .
AOM
CLINICAL
MANIFESTATIONS
Symptoms:
 Children with AOM, particularly infants, may present with
nonspecific symptoms and signs, including fever, irritability,
headache, apathy, disturbed or restless sleep,
poor feeding/anorexia, vomiting, and diarrhea .
 Fever occurs in one- to two-thirds of children with AOM,
though temperature >40°C (104°F) is unusual unless
accompanied by bacteremia or other focus of infection ,
However, ear pain and other ear-related symptoms (eg, ear
rubbing) are not always present

 Otalgia is the most common complaint in

children with AOM and the best predictor of AOM
AOM
Diagnosis
 Pneumatic otoscopy is gold standard.

 IMPORTANCE OF ACCURATE DIAGNOSIS — The

importance of accurate diagnosis of AOM cannot be
overstated.
 Accurate diagnosis ensures appropriate treatment for
children with AOM, who require antibiotic therapy, and
avoidance of antibiotics in children with otitis media
with effusion, in whom antibiotics are unnecessary.
 Accurate diagnosis also prevents overuse of
antibiotics, which leads to the development of resistant
organisms
Pneumatic otoscope
 Accurate diagnosis of AOM requires
systematic evaluation of the tympanic
membrane for:
1. Color (eg, gray, white, pale yellow, amber, pink, red, blue)
2. Other conditions (eg, fluid level, bubbles, perforation, otorrhea,
bullae, tympanosclerosis [scars], atrophic areas, retraction
pockets, cholesteatoma)
3. Mobility
4. Position (eg, neutral, retracted, full, or bulging)
5. Lighting.
6. Entire surface (the four quadrants of the tympanic membrane
should be examined) (figure 1)
7. Translucency
8. External auditory canal and auricle (eg, deformed, displaced,
inflamed, foreign body)
9. Seal (a good seal requires an airtight pneumatic system and a
speculum that is large enough to prevent air leak)
Experienced otoscopists at a tertiary care
children's hospital developed and validated a
classification scheme describing the signs and
symptoms that they use to diagnose AOM :

1. Bulging tympanic membrane (with or without

opacification or air-fluid level): AOM
2. Opacification of the tympanic membrane or air-
fluid level: OME
3. Absence of bulging, opacification, and air-fluid
level: no MEE
Cont’
AOM Diagnosis
 Position — A bulging tympanic membrane is the
hallmark of AOM. The position of the tympanic
membrane is the most critical characteristic in
distinguishing AOM from OME.
 Translucency — Translucency of the tympanic
membrane is another important aspect of the
examination.
AOM
Diagnosis
 The clinical diagnosis of AOM requires :
1. Bulging of the tympanic membrane, or
2. Very infrequently, other signs of acute
inflammation and middle ear effusion (MEE)
 A diagnosis of AOM also can be established if there
is acute purulent otorrhea and otitis externa has
been excluded
AOM
DIFFERENTIAL
DIAGNOSIS

The main consideration in the differential diagnosis of AOM is
otitis media with effusion (OME).
 Middle ear effusion (MEE) with decreased mobility and
opacification or cloudiness of the tympanic membrane occurs in
both AOM and OME. However, careful evaluation of the position,
color, and other findings of the tympanic membrane can help to
distinguish AOM from OME .
 In AOM, the tympanic membrane is usually bulging; in OME, it is
usually retracted or in the neutral position.
 In AOM, the tympanic membrane is typically white or pale yellow;
in OME, it is typically amber or blue.
 In AOM, pus may be visualized behind the tympanic membrane;
the tympanic membrane may be perforated with acute purulent
otorrhea, or bullae may be present. In OME, a fluid level or
bubbles may be seen.
RECURRENT AOM

 Recurrent acute otitis media (AOM) is defined by the

development of signs and symptoms of AOM soon
after completion of successful treatment.
 It is particularly important to establish the diagnosis of
recurrent AOM with bulging of the tympanic membrane
and signs of inflammation. Otherwise, persistent
middle ear effusion in a child with a febrile upper
respiratory infection may be misinterpreted as a
recurrent episode and the child may receive antibiotics
unnecessarily.
When recurrence occurs within 15 days of
completion of antimicrobial treatment for
the previous episode, we suggest:

 Ceftriaxone 50 mg/kg per day intramuscularly (IM)

or intravenously (IV) for three days, or
 Ceftriaxone 50 mg/kg per dose IM or IV every 36
hours for a total of two doses, or
 Levofloxacin 10 mg/kg every 12 hours orally for
10 days for children six months to five years or 10
mg/kg per once daily for 10 days for children ≥5
years (maximum 500 to 750 mg/day) [78]
When the recurrence occurs more than 15
days after completion of the treatment for
the previous episode:
 it is most often due to a different pathogen than the
previous episode. Although the child is at higher risk
for a nonsusceptible pathogen, we suggest high
dose amoxicillin-clavulanate as initial therapy, even
if the child received amoxicillin-clavulanate for the
previous episode.
 Tympanostomy tube insertion may be warranted for
children with ≥3 distinct and well-documented
episodes of AOM within six months or ≥4 episodes
within 12 months if middle ear fluid is also present
 AOM
Treatment
 Watchful waiting : current practice guidelines advise on an initial watchful waiting
without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness
because AOM symptoms improve in most within 1–3 days .
* Watchful waiting is not recommended for children < 2 years old.
 Antibiotics
Penicillin
In children < 5 years, when H. influenzae is likely to be present, amoxycillin is more effective

 Analgesics
 Nasal vasoconstrictors: The role of 0.5% ephedrine nasal drops is traditional but its
value is uncertain .
 Ear drops : Ear drops are of no value in acute otitis media with an intact drum.
 AOM fail to respond to medical therapy or develop a complication. Myringotomy is then
indicated to allow the drainage ofpus
AOM
Treatment
 Do not consider acute otitis media to be cured until
the hearing and the appearance of the membrane
have returned to normal.
 uncomplicated episodes of AOM resolves without any
adverse outcome
AOM
Treatment
 Antibiotic
 First line
 Amoxil - 60-90 mg/kg divided tid
 Ceftin - B lactam stable
 Augmentin - B lactam stable
 Bactrim, Pediazole

 Second line
 Augmentin
 Ceftin
 Rocephin
 Macrolides - Zithromax, Biaxin
 AOM
Treatment
If resolution does not occur, suspect:
 Nose, sinuses or nasopharynx Infection
 the choice or dose of antibiotic
 low-grade infection in the mastoid cells.
 Of patients who develop a perforation of the
tympanic membrane with otorrhea, a small
proportion go on to develop CSOM because of the
failure of the tympanic membrane to heal.